 |
|
Simple Clinical Predictors May Obviate Urgent Endoscopy in Selected Patients With Nonvariceal Upper Gastrointestinal Tract Bleeding
Joseph Romagnuolo, MScEpid, MD, FRCPC;
Alan N. Barkun, MScEpid, MD, CM, FRCPC;
Robert Enns, MD, FRCPC;
David Armstrong, MD, FRCPC;
Jamie Gregor, MScEpid, MD, FRCPC; for the Registry for Upper GI Bleeding and Endoscopy Investigator Group
Arch Intern Med. 2007;167(3):265-270.
Background The validated Blatchford risk score (BRS) predicts outcomes in patients with nonvariceal upper gastrointestinal tract bleeding, before endoscopy; completion of the Rockall score requires endoscopy. The aims of this study were to predict whether the modified BRS (mBRS) can predict (1) endoscopic high-risk stigmata (HRS) and (2) rebleeding and mortality.
Methods Clinical and demographic characteristics on 1869 patients from 6 Canadian provinces were prospectively entered into the Registry for Upper GI Bleeding and Endoscopy database, recording 30-day rebleeding and mortality. The Rockall score and mBRS (hemoglobin level, hemodynamic instability, and presence of melena, liver disease, or cardiac failure; urea and syncope were not recorded) were calculated. Logistic regression was used to assess the association between an mBRS of 1 or less with HRS and with rebleeding and mortality.
Results The mean (SD) age of the patients was 66 (17) years, with 62% men and a mean of 2.5 comorbidities. Of the 1860 patients with 30-day rebleeding data, 334 (18.0%) rebled; 5.3% died. The mBRS was 0 in 3% and 1 or less in 9.8% of patients; HRS were seen in 31.0% of patients. An mBRS of 1 or less was associated with lower rebleeding (5% vs 19%; P<.001) and mortality (0.5% vs 5.8%; P=.003), and was significant in multivariate analysis for rebleeding (odds ratio, 0.24; 95% confidence interval, 0.12-0.48) and mortality (odds ratio, 0.12; 95% confidence interval, 0.02-0.90). The HRS were less frequent when the mBRS was 1 or less (16.9% vs 32.7%; odds ratio, 0.4; 95% confidence interval, 0.3-0.6). Patients with a low mBRS with HRS had a low rebleeding rate (3.3%) and a lower apparent benefit from endoscopic therapy.
Conclusions An mBRS of 1 or less identifies approximately 10% of patients with gastrointestinal tract bleeding with a low likelihood of having HRS and a low risk of adverse outcomes. A prospective randomized study is required to examine whether this subgroup of patients presenting after hours could be discharged safely from emergency departments with arrangements for (urgent) outpatient endoscopy.
Author Affiliations: Departments of Medicine and Biometry, Bioinformatics and Epidemiology, Medical University of South Carolina, Charleston (Dr Romagnuolo); Departments of Medicine (Drs Barkun, Enns, Armstrong, and Gregor) and Epidemiology and Biostatistics (Dr Barkun), McGill University, Montreal, Quebec; and Departments of Medicine, University of British Columbia, Vancouver (Dr Enns), McMaster University, Hamilton, Ontario (Dr Armstrong), and University of Western Ontario, London (Dr Gregor).
 CiteULike  Connotea  Delicious  Digg  Facebook  Reddit  Technorati  Twitter
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Predictive scoring in non-trauma emergency patients: a scoping review
Challen and Goodacre
Emerg. Med. J. 2011;28:827-837.
ABSTRACT
| FULL TEXT
Upper gastrointestinal bleeding: what's the score?
Reed and Stanley
Scott Med J 2011;56:167-169.
ABSTRACT
| FULL TEXT
Emergency endoscopy cover: cost and benefits?
Barkun
Gut 2010;59:1012-1014.
FULL TEXT
International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
Barkun et al.
ANN INTERN MED 2010;152:101-113.
ABSTRACT
| FULL TEXT
Pre-Endoscopy Triage for Acute UGI Bleeding
JWatch Gastroenterology 2007;2007:2-2.
FULL TEXT
|
